Dengue: betting on homeopathy?
Posted by apgaylard on May 8, 2009
By any rational measure, betting on the effectiveness of homeopathy is not a good bet. However, many thousands of people take this chance: homeopaths stake their livelihood on it; patients bet their money, hopes and sometimes health. Medical professionals and researchers have effectively staked their careers and reputations on homeopathy working, or at least looking like it does.
Of course, confirmation bias, the self-limiting nature of many commonly treated ailments and the placebo effect all help improve the odds. Add to that a general lack of awareness of scientific methods and principles among public and policy-makers alike and betting on homeopathy is starting to look less risky.
Thinking about the research paper on homeopathy and dengue fever I’ve been looking at recently made me reflect on other possible risk reduction strategies used, subconsciously I’m sure, by the homeopathic community.
This reflection was prompted by reading a press release (translation)* issued by the author’s employers, The City of Macaé (Rio de Janeiro, Brazil). What caught my eye was the shift in emphasis on the claims made for the work. The journal paper majors on prevention and treatment:
- “The incidence of the disease in the first three months of 2008 fell 93% …”
- “[…] these results suggest that homeopathy may be an effective adjunct in Dengue outbreak prevention.”
- “The remedy was prescribed in single doses, 2 drops p.o. for prevention purposes.”
- “The intention was to diminish individual and collective susceptibility to the disease and minimize symptoms in those already or later ill.”
- “The use of homeopathy may be a useful adjunct the control of epidemics […]”
- “Homeopathic remedies can help to minimize the progression and severity of the disease and to prevent endemic and epidemic diseases, particularly those where no vaccinations are yet available.”
Yet the press release is all about symptomatic relief. Nunes is quoted as saying the, “homeopathic complex is used to reduce the symptoms of dengue”**
This tack is similar to a report (translation) apparently carried in a local newspaper, O Fluminense, where Nunes is quoted as saying, “It reminded once again that the complex is not a vaccine, just not immunizes against dengue, but helps in controlling the symptoms, avoiding the worsening of the disease“***.
It might be that these statements lose something in the limited on-line translation* I’ve performed, but it does look like these claims are more modest than those made a few months later in the ‘research’ paper.
It is true that the paper talks about reducing the “severity of the disease”; but its main focus is on preventing its spread – reducing the number of people who get infected. And the main outcome measured in the study was the reduction in reported cases of dengue, clearly interpreted by the author as an indicator that fewer people were actually infected. It was also claimed to hasten “complete remission” in symptomatic patients.
This difference in emphasis made me wonder: why were the statements offered to the local press more modest than those in the more research paper? Why the shifting goal posts?
It’s just my opinion, of course, but I can think of some possible advantages. Given that betting on homeopathy is not a good bet at all, as it’s not going to be the cause of the improvements reported for the incidence of dengue in Macaé, how could the odds be improved?
Clearly, compliance with the conventional preventative measures included in the campaign is vital: there is every chance that any impact the campaign has is a result of actions like: vector control, surveillance, public awareness etc. Undermining these by allowing people to think that homeopathy could actually protect them against becoming infected would be extremely irresponsible. It would also inevitably lead to increased incidence of dengue in the future: betting on homeopathy alone is not a good bet. And that’s not good for homeopaths either: if the emperor has no clothes it’s best to have the parade at night!
It’s also important to manage expectations: not putting comments in the local mainstream media that would set the bar for success too high in subsequent years. If the campaign in Macaé had benefitted from the “play your cards right” fallacy – starting when infections were running high and likely to fall – shifting the focus to something more vague, like reducing the perceived severity of symptoms would be helpful. In this case, subtly moving the goalposts is a good insurance policy.
In my opinion, both of these are useful strategies for reducing the risk of homeopathy being exposed as useless in areas where the campaign has already been deployed. However, such modesty is unlikely to sell the idea to other cities. That is not such good news for homeopaths. This is where the more bullish pitch of the research paper and subsequent conference poster makes sense to me.
Interestingly, my musings do seem to be borne out by reports coming out of Coronel Fabriciano, a dengue-blighted city some 560 km from Rio de Janeiro. Nunes appears to have been involved with promoting the ‘homeopathic’ approach here. In February 2009 a local paper, Jornal Hoje em Dia, reported statements promoting a ‘homeopathy campaign’ against dengue. This included some comments from Nunes.
ProMed Mail – an internet-based reporting system run by International Society for Infectious Diseases – carried an English translation of the piece.
“Coronel Fabriciano, the city with the 3rd highest rate of infestation of _Aedes aegypti_ in Minas Gerais state (6.9 per cent [house infestation rate]), added 2 deaths of suspected DHF (dengue hemorrhagic fever), causing the Municipality of Coronel Fabriciano to take more energetic measures to contain a possible epidemic. The betting is on homeopathy. Joint efforts will be made starting tomorrow, across the city, so that the population of about 105 000 inhabitants, take without charge the 2 drops of a homeopathic remedy that promises to decrease the body’s susceptibility to dengue [virus infection], and mitigate the effects of the disease.
The novel [treatment] comes from the city of Macae (Rio de Janeiro), [carried out at] the hands of homeopath and medical coordinator of the Public Health of the Municipality of that city, Leila Nunes. According to specialists, while the neighboring cities recorded up to a 300 per cent increase of the disease, Macae had a significant reduction in its [dengue] indices. “After distributing the product, reported dengue cases were reduced by up to 65 per cent in 2008, compared to the previous year . In the 1st 3 months of 2008, compared with the same period of 2007, the rate of dengue cases fell by 93 per cent. We started the application [of the drug] in the population during the peak of the epidemic. We noticed the drop in cases that still occurred that year , but was much more abrupt than in years earlier,” said the doctor. […]”
Reducing the symptoms of the disease still features in the report, but the focus is very similar to that of the research paper: prevention. Clearly, this sales pitch relies on the reduction of infections.
To me, this looks like a marketing strategy: down-play the more risky ‘hard’ measure where the ‘homeopathy’ campaign has already been established. After all, the brand has already been established. However, to conquer new markets: talk it up – at least until you’ve got a foothold.
There is, of course, another risk-reduction strategy embedded in this approach: the magician’s misdirection. The campaign is touted as a ‘homeopathic’ intervention, but there’s the “great social mobilization” aspect of the campaign at work as well! This contains many other measures – which are overwhelmingly the likely source of any benefit. This sleight of hand is seen in the journalist contending that, “The betting is on homeopathy” when the article goes on to quote the City Prefect, Chico Simoes, describing the more conventional aspects of the campaign:
“We created a volunteer cleanup force, for “project clean up stuff”, [public] awareness campaigns, and the dial-dengue [information telephone line]. We have more health workers than recommended by the Ministry Health and most recently passed a law authorizing the city government to impose fines of BRL 680 to BRL 1380 [USD 300-609] for people who do not cooperate in the elimination the focus [breeding sites] of _Aedes aegypti_. Still, the index of infestation is high. Lack of awareness in the population and this will take time to change. Dengue in Fabriciano may worsen still further […]”
This sounds very much like the “great social mobilization against dengue” that Nunes told me formed part of the approach in Macaé. In Coronel Fabriciano they even deployed the Army:
“Military Armed Forces will also tackle the mosquito transmits dengue [virus] in the state. Today [8 Feb 2009] ends the training course given by the state Secretariat for 100 soldiers of the 12th Infantry Battalion (IB) of Belo Horizonte. Another 200 soldiers will be trained in next 2 weeks to participate in activities in the region or in other cities in the state. The participation of the Armed Forces to fight _Aedes aegypti_ was through an agreement between the Ministries of Health and Defense. The idea is to train 2000 soldiers in Brazil.
This 1st group of soldiers must act initially intersectorially in the 9 regions of the Belo Horizonte prefecture and in surrounding towns that have registered large numbers of mosquito infestations or that have few staff for health and zoonoses control [available] to make visits and to combat outbreaks. In training, the military were introduced to [diflubenzuron], a new insecticide that will be adopted, that is more effective and less toxic.
The elements seen in the campaign in Macaé appear to be in place: a high rate of infections maximising the chance of a subsequent reduction (play your cards right) and an aggressive programme of conventional countermeasures (magician’s misdirection).
If the number of dengue infections in Coronel Fabriciano go down in 2009 it’s a good bet that the headlines will be about the wonders of homeopathy. And if this year’s numbers aren’t as good in Macaé: I’d give good odds that the focus will be on the more modest claims released to the local press.
Now, I could be wrong; this is just my opinion. Neither am I suggesting a conscious deception; in fact I’m convinced that Nunes has a sincere belief homeopathy (translation). Perhaps as a consequence, it seems to me like betting on homeopathy is being made into a one-way bet. A combination of goal post shifting and misdirection is staking the deck in favour of the interests of homeopaths and the suppliers of these ‘remedies’.
However, there are losers. Public funds and resources will be squandered on administering rites with magic water. The public understanding of how the human body works will continue to be undermined; ditto for the public’s appreciation of the values, methods and knowledge embodied in science. And occasionally someone will be tempted to think that homeopathy actually works and will try to use it as an alternative to medicine for something serious. Among these will be the biggest losers of all.
Nunes LAS. Contribution of homeopathy to the control of an outbreak of dengue in Macaé, Rio de Janeiro. Int J High Dilution Res [online]. 2008 [cited 2009 May 07]; 7(25): 186-192. Available from: http://www.feg.unesp.br/~ojs/index.php/ijhdr/article/view/315/374
Oliveira, G. [Macaé: success of the campaign against dengue in international conference]. City of Macaé, 18th September 2008. http://www.macae.rj.gov.br/noticias/mostranot.asp?id=14229 Accessed 07 May 2009.
ProMED-mail. PRO/EDR> Dengue/DHF update 2009. ProMED-mail 2009; 10 Feb: 20090210.0610. http://www.promedmail.org . Accessed 07 May 2009.
Mojo on the Bad Science Forum for the colourful “play your cards right” fallacy.
9th May 2009. Some minor typos corrected.
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